Othman Bilyaminu Othman is the highly regarded Emir of Dass, in Dass Local Government Area of Bauchi State of Nigeria. He is a traditional sovereign with an unusual passion, a passion for maternal, new born and child health.
Recently, a visitor to his palace, curious about his zeal dared asked him for a personal experience that was responsible for it. And he graciously responded, telling a story.
The Emir told of how, on an exercise to monitor health facilities in Bauchi State, he had to travel to a very remote area in the company of government officials on a bumpy road for three hours into a backwater community where they found a decrepit building disguising as a public health centre.
On arrival, they expectedly asked for the officer-in-charge of the health facility. The community pointed to a woman who had been selling drugs, taking delivery of babies, and treating health cases in the facility. But this woman was discovered not to be anything close to a health worker or even a government official in training.
In fact, she never completed her elementary education. Why this? Health workers assigned to this community always left as soon as they were posted there because of its remoteness and other factors. So, she chose to fill the gap in a community with low literacy level and make a life of being a pharmacist, gynecologist, obstetrician and midwife wrapped in one. For the Emir, the situation had to change.
Childbirth is natural and that takes place in every community in the world and at any time of the day. Many factors, including ill-equipped personnel like the one mentioned above, inadequacy of health facilities, dearth of health personnel, community cultural values and sheer lack of political will, all conspire against the well being of mothers, newborns and under-five children in Nigeria.
Although the country has only about two percent of the global population, it accounts for 13 percent of the world’s annual maternal and child mortality. With maternal death rate of 545 deaths per 100,000, Nigeria, Somalia, Mali, DR Congo and Niger have been considered to be among the 10 ‘worst places in the world to be a mother.’
Meanwhile, of the 36 states in Nigeria, Sokoto in the Northwest and Bauchi in the Northeast were among the worst hit by maternal, newborn and child deaths in the country. Both access to, and demand for, mother and child healthcare in these states were unacceptably low.
For instance, in Bauchi state, 87 percent of women would rather have their babies at home than go to the maternity clinic or any health facility at all. It was also discovered in 2008 that only 14 percent of pregnant women in Sokoto State received antenatal services meanwhile 95 percent delivered at home and a large number of them did without any professional aid whatsoever.
Factors responsible for this state of affairs are diverse. Apart from the fact of inadequacy of facilities and scarcity of skilled health workers, it had been a century-old thing of pride in these areas for a formerly pregnant woman to emerge from her bedroom saying: “Hey, I just delivered a set of twins by myself.” But sometimes, the end result is fatal.
Postpartum hemorrhage (doctors’ way of referring to excessive bleeding by women after childbirth) has been found to be responsible for the highest number of maternal deaths in Nigeria, while infection of the umbilical cord, malaria, and diarrhea were fingered as responsible for the highest number of newborn and under-five deaths in the country.
About six years ago, the John Snow Research and Training Institute, Inc. (JSI), backed by the United States Agency for International Development (USAID) began the Targeted States High Impact Project (TSHIP) to promote the wellbeing of Nigerians with Sokoto and Bauchi State as pilot States. TSHIP, for all the years from 2009 till recently had carried out various interventions impacting the lives of women and children in these two states. The project employed a multi-pronged approach to helping women and babies survive more.
“The decision to initially intervene in Sokoto and Bauchi was made by USAID in consultation with the government of Nigeria at the inception of the project in 2009. However, part of the aspiration of working in these two states was that lessons gained will be shared with other states,” said Nosa Orobaton TSHIP’s Chief of Party.
To stem the very urgent challenge of maternal and newborn death from post-partum hemorrhage and umbilical cord infection, the federal government of Nigeria approved and project commissioned and advocated for the use of two life-saving commodities of misoprostol and chlorhexidine for new mothers and their babies respectively.
Misoprostol protects the mother from excessive bleeding after birth (postpartum hemorrhage). While Misoprostol is available in Nigeria, TSHIP’s advocacy led to the development of the single-dose, three-pill prescription suitable for preventing postpartum hemorrhage (PPH).
Chlorhexidine on its own part is an easy-to-use antiseptic gel, which when applied on the newborn’s cord stump within an hour after birth, seals the wound, preventing bacteria from infecting it and allowing it to heal. When used together, misoprostol and chlorhexidine offer critical protection to both mother and child in the delicate period just after childbirth referred to as ‘The Golden Hour.’
In 2013, Sokoto state government imported chlorhexidine from Nepal, thus becoming the first government in Africa to adopt the gel for cord care. Delegations from 31 of 36 Nigerian states, plus the capital, Abuja, have so far undertaken study tours of Sokoto’s program. Delegations of medical professional organisations have equally visited Bauchi state for critical learning.
In 2014, a Nigerian pharmaceutical company pioneered the manufacture of chlorhexidine in Africa. USAID improved the commodity security from zero local producers in 2013 to two producers in 2015 with a combined annual capacity to produce over 60 million tubes of the gel, 8 times the national need.
Additionally, USAID’s TSHIP also assisted Nigeria to bring on board an additional supplier of misoprostol thereby pushing down the product’s unit price.
A challenge however emerged with getting the women to use these drugs in those communities where a very low percentage of women access medical services. Appropriate approaches were therefore developed to reach women, especially those who would deliver in their homes or where no one is present.
USAID and partners successfully advocated for the inclusion of the two drugs in the essential medicines lists at state and national levels. For this intervention and others that TSHIP carried out in the two states of Bauchi and Sokoto, local communities were involved. State governments for instance, adopted the national policy on ward minimum health care package to increase access to and utilization of basic maternal and child health services.
This necessitated the activation of the Ward Development Committees (WDC), which TSHIP helped to realiize in all wards across the states. These WDCs were responsible for the management of the flow of health commodities in their local health facility. The platform was also adopted to increase acceptance of TSHIP’s interventions in their various communities.
TSHIP established a functional community-based health program that promoted healthy household practices and expanded access to and use of facility-based services, and trained a new cadre of skilled community-based health volunteers (CBHVs) to implement it. Their activities are of immense effectiveness. They helped also to enlighten the traditional birth attendants and the women to refer complicated cases of childbirth to health facilities.
This is why the Emir of Das, Alhaji Bilyaminu said “We have seen success overtime in MNCH in our communities. In those days, women were not even allowed to attend antenatal care, not to talk of delivering their babies in health facilities. The challenges of rejection of health personnel which was high in rate have now been tackled. TSHIP has helped to upgrade our facilities, personnel were trained by TSHIP. Things are no more the way they used to be.”
The rate of success is no doubt impressive. So far, more than one million newborns in Nigeria have been treated with chlorhexidine. In target states, data is already showing reductions in both cord infections and postpartum hemorrhage. The challenge in it is securing the buy-in of the various states governments. Sokoto has set the pace with the improvement in health financing.
The Bauchi state government is also determined to sustain the tempo.
In the words of a top official of Bauchi state’s Directorate of Public Health, Bako Gamawa, “The government is doing a lot and I can assure you that we are not letting our people down. The efforts that went into the work of TSHIP will not be in vain.”
According to him, the Bauchi State Government has taken positive steps to ensure that many of the programmes initiated by TSHIP in Bauchi state are integrated into the systems of the state. Gamawa made particular reference to the success achieved in the area of maternal, newborn and child health which is impacting the lives of children and women of child-bearing age.
For Nigeria to therefore come out of the club of countries with unacceptably high maternal, newborn and child mortality rate, other states of the federation will need to adopt similar approaches to results being recorded in States like Bauchi and Sokoto .
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